Provider Demographics
NPI:1790725380
Name:SHANNON, BRIAN PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PAUL
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 C GRANITE STREET
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891
Mailing Address - Country:US
Mailing Address - Phone:401-596-8720
Mailing Address - Fax:401-596-5403
Practice Address - Street 1:130 C GRANITE STREET
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891
Practice Address - Country:US
Practice Address - Phone:401-596-8720
Practice Address - Fax:401-596-5403
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI22631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry